Introduction: Infections are a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). An increased susceptibility to infections exists in SLE patients, either related to immunosuppressive therapies or from disease-related immunological dysfunction. Central nervous system (CNS) infections in patients with SLE are rare, affecting approximately 1.4% of patients; however, a death rate of higher than 40% has been reported in this patient group. Case Description: A 68-year-old female with history of SLE, ischemic cardiomyopathy, and chronic diarrhea presented with acute worsening of diarrhea and rectal pain over 3 days. She had been hospitalized the prior month for new choreiform movements and dysarthria believed to be secondary to CNS involvement of SLE; at the time, she had been taking prednisone 40 mg daily and mycophenolate 750 mg twice daily for immunosuppression. Notable labs included leukocytosis 11.9 K/mcL, sodium 128 mmol/L, bicarbonate 18 mmol/L, glucose 273 mg/dL, BUN 30 mg/dL, and creatinine 1.25 mg/dL. Patient developed altered mentation with high fevers shortly after admission and was emergently intubated, then transferred to ICU; CT head was negative and lumbar puncture (LP) was performed. Empiric IV cefepime, vancomycin, ampicillin, acyclovir and oral vancomycin were started. Cerebrospinal fluid (CSF) culture and rapid meningitis panel grew Listeria monocytogenes, as did initial blood cultures. Repeat blood and CSF cultures were negative, and she completed antibiotic treatment for 3 weeks. Patient clinically improved and was transitioned back to her home from skilled nursing facility. Discussion: Due to their similar manifestations, CNS infections and neuropsychiatric systemic lupus erythematosus (NPSLE) may be difficult to distinguish. The most common pathogens involved in CNS infections in SLE patients include M. tuberculosis, C. neoformans, and L. monocytogenes. A transient gastroenteritis may precede Listeria meningitis, providing an important clue for accurate diagnosis and therapy. In order to mitigate high mortality, clinicians must have clinical suspicion for meningitis and respond with early diagnosis and treatment
